- Email: [email protected]
Ebola: better protection needed for Guinean health-care workers
Correspondence
We welcome the publication of the Lancet Commission (Nov 29, p 1953)1 on liver disease in the UK and its important recommendations to improve care for this growing population of patients. However, we were surprised to see minimum reference to the provision of high quality supportive and palliative care for the many patients dying with advanced liver disease. The report makes clear how common death from liver disease is. The population with liver disease is younger and growing faster than populations with other types of organ failure, and has many complex needs. We fully support the directed measures to reduce preventable deaths, but the fact remains that for the foreseeable future many patients will continue to die. A clear and immediate need exists for evidence-based guidance about best practice in care of people with advanced liver disease to ensure that they are identified as being at risk of further deterioration and death, and then receive appropriate supportive care alongside optimum treatment of their disease. This issue is emphasised in Getting it Right: Improving End of Life Care for People Living with Liver Disease, a report by the NHS Liver Care published in 2013. Clear guidance exists for the palliative care of non-malignant end-stage disease in the kidney, lung, and heart. However, a pressing need and opportunity exist to develop programmes of research to inform the development of such guidelines for liver disease too.2 We declare no competing interests.
Barbara Kimbell, Kirsty Boyd, Alastair MacGilchrist, *Scott A Murray [email protected] Primary Palliative Care Research Group, University of Edinburgh, Edinburgh EH8 9AG, UK (BK, KB, SAM); and Royal Infirmary of Edinburgh, Edinburgh, UK (AMacG)
www.thelancet.com Vol 385 February 7, 2015
1
2
Williams R, Aspinall R, Bellis M, et al. Addressing liver disease in the UK: a blueprint for attaining excellence in health care and reducing premature mortality from lifestyle issues of excess consumption of alcohol, obesity, and viral hepatitis. Lancet 2014; 384: 1953–97. Boyd K, Kimbell B, Murray SA, Iredale J. Living and dying well with advanced liver disease: time for palliative care? Hepatology 2012; 55: 1650–51.
As patient groups and hepatologists we applaud and support the work of the Lancet Commission1 in drawing attention to the growing problem of chronic liver disease in the UK. However, we are concerned that the focus was only on lifestyle-related liver disease. 1 We do not doubt of the importance of alcoholic, obesity-related, and viral liver diseases, but other important causes of liver failure exist. For example, the lives of more than 30 000 patients in the UK are estimated to be affected by autoimmune liver disorders 2 such as primary biliary cirrhosis, primary sclerosing cholangitis, and autoimmune hepatitis—indeed the number of patients with autoimmune liver disease is higher than those with cystic fibrosis (about 10 000).3 Primary biliary cirrhosis and autoimmune hepatitis can often be treated effectively, particularly with early diagnosis. If such patients are not treated at an early stage, or in the case of primary sclerosing cholangitis for which no medical treatment exists, they are likely to progress to cirrhosis, incurring the costs and risks of end-stage liver disease. Neglect of these rare but potentially treatable forms of liver disease because of their low prevalence denies the effect that these conditions have on individual patients, and could lead to missed opportunities for patients to receive effective and potentially life-changing treatment. We call upon all those delivering liver-related health care to focus their efforts on future care pathways to include all causes of liver disease, and also to ensure that access to care is uniform; includes the ability
to refer patients, when needed, to specialist centres of excellence; and aids primary care teams to promptly diagnose patients with liver disease for effective treatment.
Dr P Marazzi/Science Photo Library
Liver disease in the UK
GMH is an investigator and consultant for Intercept Pharma, FalkPharma, BioTie, Lumena, Gilead, GlaxoSmithKline, Janssen, and FFPharma. CT, MW, AB, and DEJ declare no competing interests.
Gideon M Hirschfield, Collette Thain, Martine Walmsley, Ann Brownlee, *David E Jones [email protected] Centre for Liver Research, National Institute for Health Research Biomedical Research Unit, University of Birmingham, Birmingham, UK (GMH); PBC Foundation, Edinburgh, UK (CT); PSC Support, Didcot, Oxfordshire, UK (MW); AIH Support, Bath, UK (AB); and Medical School, Newcastle University, Newcastle upon Tyne NE2 4HH, UK (DEJ) 1
2
3
Williams R, Aspinall R, Bellis M, et al. Addressing liver disease in the UK: a blueprint for attaining excellence in health care and reducing premature mortality from lifestyle issues of excess consumption of alcohol, obesity, and viral hepatitis. Lancet 2014; 384: 1953–97. Dyson JK, Webb G, Hirschfield GM, et al. Unmet clinical need in autoimmune liver diseases. J Hepatol 2015; 62: 208–18. Cystic Fibrosis Trust. UK Cystic fibrosis registry annual data report 2013. London: Cystic Fibrosis Trust, 2014.
Ebola: better protection needed for Guinean health-care workers The situation for health-care workers affected by Ebola in Guinea is quite similar to that of Sierra Leone described in a recent Editorial (Dec 20, p 2174).1 As of Dec 30, 2014, in Guinea 2419 laboratory-confirmed cases of Ebola were reported, of which 151 (6·2%) were in health-care workers.2 Although the case fatality rate is lower in health-care workers (52·3%) than in the general population (59·9%),2 there are concerns regarding the doubling of laboratory-confirmed Ebola infections in health-care workers during the past weeks compared with decreases in the general population (figure).2 This rise merits attention. First, if the number of deaths of health-care
For the report Getting it Right: Improving End of Life Care for People Living with Liver Disease see http://www.yhln.org.uk/ data/documents/2013/NHS%20 Liver%20Care,%20Getting%20 it%20Right%20-%20 Improving%20End%20of%20 Life%20Care%20for%20 People%20with%20Liver%20 Disease.pdf
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
503
Correspondence
*Alexandre Delamou, Abdoul Habib Beavogui, Mandy Kader Kondé, Johan van Griensven, Vincent De Brouwere
General population Health-care workers
450
Number of people infected with Ebola
400 350
[email protected]
300
Centre de Formation et de Recherche en Santé Rurale de Maferinyah, Forecariah, Guinea (AD, AHB); Centre d’Excellence de Formation & Recherche sur le Paludisme et les Maladies Prioritaires en Guinée, Conakry, Guinea (MKK); and Clinical Sciences Department (JvG) and Woman & Child Health Research Centre (VDB), Institute of Tropical Medicine, Antwerp, Belgium
250 200 150 100
1
50
2 0
1–8
9–12
13–16
17–20
21–24
25–28
29–32
33–36
37–40
41–44
45–48
49–52
Weeks
Figure: Laboratory-confirmed Ebola infections in health-care workers and the general population in Guinea, Dec 30, 2013, to Dec 30, 2014 Data are from reference 2 by the WHO and National Coordination Against Ebola summarising accumulated data of Ebola in Guinea, generated on Dec 30, 2014.
workers in Guinea continues at the present rate, the fragile health system3,4 might be further weakened and could collapse because of the shortage of health-care personnel. Additionally, specific areas of care, such as maternity care, might not be provided.5 Second, any additional deaths of health-care workers will reinforce the view of some in the population that health facilities are still not the safest places to seek care.5 Finally, the increasing number of health-care workers affected engenders the refusal of communities to collaborate with Ebola control teams—who might be accused of spreading the disease. Such refusal could weaken efforts to stop Ebola. Although there is a need to investigate, identify, and address ongoing prevention failures, 1 it is important to note that it is not only doctors and nurses, but also community health workers that are affected. As more people reaching out to communities are needed to combat this disease they also need to be well prepared and protected. From our experience in Conakry, Guinea, most health-care workers’ contaminations were due to the insufficient measures for prevention and infection control 504
in a context where systematic hand washing and use of gloves in health facilities are not standard practice. Contamination has been reported within communities (eg, from unsafe burial ceremonies) in addition to those in the workplace, from relatives who are ill, neighbours, or suspected cases that escape the disease surveillance system. We agree that prevention of Ebola in health-care workers is crucial to improve the health response to all causes of morbidity and mortality in countries affected by Ebola. 1 More efforts are needed in Guinea to reinforce health-care workers’ capabilities to protect themselves, to identify and refer suspected cases of disease, and to rebuild trust with communities and medical staff. Additionally, health-care workers located in the sites of clinical trials need special protective measures because these studies entail invasive procedures. Local personnel should get the same care as expatriate health-care workers receive from their countries.6 AD, MKK, and JvG are part of the Ebola_Tx Consortium, an Insititute of Tropical Medicine-led consortium on convalescent serum, which received funding from the European Union’s Horizon 2020 research and innovation programme. We declare no competing interests.
3
4
5
6
The Lancet. Ebola: protection of health-care workers. Lancet 2014; 384: 2174. Coordination Nationale Ebola in Guinée, OMS. Rapport de la Situation Epidémiologique, Maladie à Virus Ebola en Guinée du 30 Decembre 2014. Sit_Rep_no 259. Conakry, Guinea: Coordination Nationale Ebola Guinée and Organisation mondiale de la Santé, 2014. Kieny M, Evans D, Schmets G, Kadandale S. Health-system resilience: reflections on the Ebola crisis in western Africa. Bull World Health Organ 2014; 92: 850. Piot P, Muyembe J-J, Edmunds WJ. Ebola in west Africa: from disease outbreak to humanitarian crisis. Lancet Infect Dis 2014; 14: 1034–35. Delamou A, Hammonds R, Caluwaerts S, Utz B, Delvaux T. Ebola in Africa: beyond epidemics, reproductive health in crisis. Lancet 2014; 384: 2105. Shuchman M. Sierra Leone doctors call for better Ebola care for colleagues. Lancet 2014; 384: e67.
Apgar score and risk of cause-specific infant mortality We read with interest Stamatina Iliodromiti and colleagues’ study of the Apgar score and the risk of cause-specific infant mortality (Nov 15, p 1749).1 In this Article,1 outcomes of deliveries between 1992 and 2010, in Scotland, UK, were studied, and more than one million livebirths were analysed. The authors reported a strong association between a low Apgar score at 5 min and the risk of neonatal and infant death.1 Analyses of data were restricted to births “in girls or women older than 10 years”,1 but the authors did not state why this criterion was used. From this exclusion criterion, an assumption could be made that girls younger than 10 years in Scotland, UK, www.thelancet.com Vol 385 February 7, 2015
We welcome the publication of the Lancet Commission (Nov 29, p 1953)1 on liver disease in the UK and its important recommendations to improve care for this growing population of patients. However, we were surprised to see minimum reference to the provision of high quality supportive and palliative care for the many patients dying with advanced liver disease. The report makes clear how common death from liver disease is. The population with liver disease is younger and growing faster than populations with other types of organ failure, and has many complex needs. We fully support the directed measures to reduce preventable deaths, but the fact remains that for the foreseeable future many patients will continue to die. A clear and immediate need exists for evidence-based guidance about best practice in care of people with advanced liver disease to ensure that they are identified as being at risk of further deterioration and death, and then receive appropriate supportive care alongside optimum treatment of their disease. This issue is emphasised in Getting it Right: Improving End of Life Care for People Living with Liver Disease, a report by the NHS Liver Care published in 2013. Clear guidance exists for the palliative care of non-malignant end-stage disease in the kidney, lung, and heart. However, a pressing need and opportunity exist to develop programmes of research to inform the development of such guidelines for liver disease too.2 We declare no competing interests.
Barbara Kimbell, Kirsty Boyd, Alastair MacGilchrist, *Scott A Murray [email protected] Primary Palliative Care Research Group, University of Edinburgh, Edinburgh EH8 9AG, UK (BK, KB, SAM); and Royal Infirmary of Edinburgh, Edinburgh, UK (AMacG)
www.thelancet.com Vol 385 February 7, 2015
1
2
Williams R, Aspinall R, Bellis M, et al. Addressing liver disease in the UK: a blueprint for attaining excellence in health care and reducing premature mortality from lifestyle issues of excess consumption of alcohol, obesity, and viral hepatitis. Lancet 2014; 384: 1953–97. Boyd K, Kimbell B, Murray SA, Iredale J. Living and dying well with advanced liver disease: time for palliative care? Hepatology 2012; 55: 1650–51.
As patient groups and hepatologists we applaud and support the work of the Lancet Commission1 in drawing attention to the growing problem of chronic liver disease in the UK. However, we are concerned that the focus was only on lifestyle-related liver disease. 1 We do not doubt of the importance of alcoholic, obesity-related, and viral liver diseases, but other important causes of liver failure exist. For example, the lives of more than 30 000 patients in the UK are estimated to be affected by autoimmune liver disorders 2 such as primary biliary cirrhosis, primary sclerosing cholangitis, and autoimmune hepatitis—indeed the number of patients with autoimmune liver disease is higher than those with cystic fibrosis (about 10 000).3 Primary biliary cirrhosis and autoimmune hepatitis can often be treated effectively, particularly with early diagnosis. If such patients are not treated at an early stage, or in the case of primary sclerosing cholangitis for which no medical treatment exists, they are likely to progress to cirrhosis, incurring the costs and risks of end-stage liver disease. Neglect of these rare but potentially treatable forms of liver disease because of their low prevalence denies the effect that these conditions have on individual patients, and could lead to missed opportunities for patients to receive effective and potentially life-changing treatment. We call upon all those delivering liver-related health care to focus their efforts on future care pathways to include all causes of liver disease, and also to ensure that access to care is uniform; includes the ability
to refer patients, when needed, to specialist centres of excellence; and aids primary care teams to promptly diagnose patients with liver disease for effective treatment.
Dr P Marazzi/Science Photo Library
Liver disease in the UK
GMH is an investigator and consultant for Intercept Pharma, FalkPharma, BioTie, Lumena, Gilead, GlaxoSmithKline, Janssen, and FFPharma. CT, MW, AB, and DEJ declare no competing interests.
Gideon M Hirschfield, Collette Thain, Martine Walmsley, Ann Brownlee, *David E Jones [email protected] Centre for Liver Research, National Institute for Health Research Biomedical Research Unit, University of Birmingham, Birmingham, UK (GMH); PBC Foundation, Edinburgh, UK (CT); PSC Support, Didcot, Oxfordshire, UK (MW); AIH Support, Bath, UK (AB); and Medical School, Newcastle University, Newcastle upon Tyne NE2 4HH, UK (DEJ) 1
2
3
Williams R, Aspinall R, Bellis M, et al. Addressing liver disease in the UK: a blueprint for attaining excellence in health care and reducing premature mortality from lifestyle issues of excess consumption of alcohol, obesity, and viral hepatitis. Lancet 2014; 384: 1953–97. Dyson JK, Webb G, Hirschfield GM, et al. Unmet clinical need in autoimmune liver diseases. J Hepatol 2015; 62: 208–18. Cystic Fibrosis Trust. UK Cystic fibrosis registry annual data report 2013. London: Cystic Fibrosis Trust, 2014.
Ebola: better protection needed for Guinean health-care workers The situation for health-care workers affected by Ebola in Guinea is quite similar to that of Sierra Leone described in a recent Editorial (Dec 20, p 2174).1 As of Dec 30, 2014, in Guinea 2419 laboratory-confirmed cases of Ebola were reported, of which 151 (6·2%) were in health-care workers.2 Although the case fatality rate is lower in health-care workers (52·3%) than in the general population (59·9%),2 there are concerns regarding the doubling of laboratory-confirmed Ebola infections in health-care workers during the past weeks compared with decreases in the general population (figure).2 This rise merits attention. First, if the number of deaths of health-care
For the report Getting it Right: Improving End of Life Care for People Living with Liver Disease see http://www.yhln.org.uk/ data/documents/2013/NHS%20 Liver%20Care,%20Getting%20 it%20Right%20-%20 Improving%20End%20of%20 Life%20Care%20for%20 People%20with%20Liver%20 Disease.pdf
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
503
Correspondence
*Alexandre Delamou, Abdoul Habib Beavogui, Mandy Kader Kondé, Johan van Griensven, Vincent De Brouwere
General population Health-care workers
450
Number of people infected with Ebola
400 350
[email protected]
300
Centre de Formation et de Recherche en Santé Rurale de Maferinyah, Forecariah, Guinea (AD, AHB); Centre d’Excellence de Formation & Recherche sur le Paludisme et les Maladies Prioritaires en Guinée, Conakry, Guinea (MKK); and Clinical Sciences Department (JvG) and Woman & Child Health Research Centre (VDB), Institute of Tropical Medicine, Antwerp, Belgium
250 200 150 100
1
50
2 0
1–8
9–12
13–16
17–20
21–24
25–28
29–32
33–36
37–40
41–44
45–48
49–52
Weeks
Figure: Laboratory-confirmed Ebola infections in health-care workers and the general population in Guinea, Dec 30, 2013, to Dec 30, 2014 Data are from reference 2 by the WHO and National Coordination Against Ebola summarising accumulated data of Ebola in Guinea, generated on Dec 30, 2014.
workers in Guinea continues at the present rate, the fragile health system3,4 might be further weakened and could collapse because of the shortage of health-care personnel. Additionally, specific areas of care, such as maternity care, might not be provided.5 Second, any additional deaths of health-care workers will reinforce the view of some in the population that health facilities are still not the safest places to seek care.5 Finally, the increasing number of health-care workers affected engenders the refusal of communities to collaborate with Ebola control teams—who might be accused of spreading the disease. Such refusal could weaken efforts to stop Ebola. Although there is a need to investigate, identify, and address ongoing prevention failures, 1 it is important to note that it is not only doctors and nurses, but also community health workers that are affected. As more people reaching out to communities are needed to combat this disease they also need to be well prepared and protected. From our experience in Conakry, Guinea, most health-care workers’ contaminations were due to the insufficient measures for prevention and infection control 504
in a context where systematic hand washing and use of gloves in health facilities are not standard practice. Contamination has been reported within communities (eg, from unsafe burial ceremonies) in addition to those in the workplace, from relatives who are ill, neighbours, or suspected cases that escape the disease surveillance system. We agree that prevention of Ebola in health-care workers is crucial to improve the health response to all causes of morbidity and mortality in countries affected by Ebola. 1 More efforts are needed in Guinea to reinforce health-care workers’ capabilities to protect themselves, to identify and refer suspected cases of disease, and to rebuild trust with communities and medical staff. Additionally, health-care workers located in the sites of clinical trials need special protective measures because these studies entail invasive procedures. Local personnel should get the same care as expatriate health-care workers receive from their countries.6 AD, MKK, and JvG are part of the Ebola_Tx Consortium, an Insititute of Tropical Medicine-led consortium on convalescent serum, which received funding from the European Union’s Horizon 2020 research and innovation programme. We declare no competing interests.
3
4
5
6
The Lancet. Ebola: protection of health-care workers. Lancet 2014; 384: 2174. Coordination Nationale Ebola in Guinée, OMS. Rapport de la Situation Epidémiologique, Maladie à Virus Ebola en Guinée du 30 Decembre 2014. Sit_Rep_no 259. Conakry, Guinea: Coordination Nationale Ebola Guinée and Organisation mondiale de la Santé, 2014. Kieny M, Evans D, Schmets G, Kadandale S. Health-system resilience: reflections on the Ebola crisis in western Africa. Bull World Health Organ 2014; 92: 850. Piot P, Muyembe J-J, Edmunds WJ. Ebola in west Africa: from disease outbreak to humanitarian crisis. Lancet Infect Dis 2014; 14: 1034–35. Delamou A, Hammonds R, Caluwaerts S, Utz B, Delvaux T. Ebola in Africa: beyond epidemics, reproductive health in crisis. Lancet 2014; 384: 2105. Shuchman M. Sierra Leone doctors call for better Ebola care for colleagues. Lancet 2014; 384: e67.
Apgar score and risk of cause-specific infant mortality We read with interest Stamatina Iliodromiti and colleagues’ study of the Apgar score and the risk of cause-specific infant mortality (Nov 15, p 1749).1 In this Article,1 outcomes of deliveries between 1992 and 2010, in Scotland, UK, were studied, and more than one million livebirths were analysed. The authors reported a strong association between a low Apgar score at 5 min and the risk of neonatal and infant death.1 Analyses of data were restricted to births “in girls or women older than 10 years”,1 but the authors did not state why this criterion was used. From this exclusion criterion, an assumption could be made that girls younger than 10 years in Scotland, UK, www.thelancet.com Vol 385 February 7, 2015